GW1--04118_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
IV 1 n rK A-I I-eex)I 14.WATER ZONES
t FROM TO DESCRIPTION
Well Contractor Name ft. ft.
n Z A ft. ft-
15.OUTER CASING(for multi-cased wells)OR LINER(if ap Ileable)
NC Well Contractor Certification Number PROM TO DIAMETER THICKNESS MATERIAL
_
Clearwater Well Drilling Inc. / fi. it.,2 it. Lr2 %d=ia_ ✓t_2
Company Name 16.INNER CASING OR TUBING(geothermal dosedaoop)
� � 1 (��� FROM TO DIAMETER THICKNESS MATERIAL
yt
2.Well Construction Permit#: ft. ft. in.
List Olt applicable well construction permits(i.e.Count}•,State,Variance,etc.) ft ft. fo.
3.Well Use(check well use): 17.SCREEN
Water SupplyWell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public ----
ft. ft. im
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) _
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO nMATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation / ft- f).9 R' C lain/)r tr7/A/LI
Non-Water Supply Well: ft. ft.
0 Monitoring ❑Recovery -
ft. R.
Injection Well: - _
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable
FROM TO MATERIAL _ EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft,
❑Aquifer Test ❑Stormwater Drainage ft. it.
❑Lxperimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO ( DESCRIPTION(eakr,I ardx .nso,Urock type,grain tier,etc.) (
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) / R' j Uy/0n it al ff�)('{ Y E1�
W
rr0� -)( Well ID# /v0� 3C1 it (`f>(�(.(Ifi/e
4.Date Well(s)Completed: V( it r. �7 D. J0_,6/'/,1
5a.Well Location 3�I 7 ft. `/66 ft. / /� y4/l (�.
0.0 I hbrown ff. n. ! (P%lt/1 T t
Facility1139(if applicable) ,
Facility/Ow Name Lot 3 PP ) tt• ft. ,lM �E�}
LyI-I CCouc / d . 3h oft, .t u« n. ft. 1 I} ?(�
Physical Address,City,and Zip /t VtC /
21.REMARKS i I J` 1 2 202A4
l" ii i-7(2-pin be,. � Its tto.r a t*!t ' --:a;'Jr,
Parcel Identification No.(PIN) DI..:3$G.;
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.0 :
(if well field,one tat/long is sufficient)
35'S�f yl. 30 N 8� '37 37. 0,? W t.
Signature o Certified Well Con or Date
6.Is(are)the well(s): 0ermanent or 0Temporary g}.,ignin this form./hereby crrtif)r that the„ell(s)nor(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC UsC.0200 Well Construction Standards and that a
7.is this a repair to an existing well: Oyes or FIO ropy of or record hos been provided to iF,e well owner.
If this is a repair,fill out known welt construction information and exploit,the nature of the Si diagram or additional well details:
repair under#21 remarks section or on the back of thin form.
23.You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-linter supply,tells ONLY with the same construction,;au can SUBMITTAL INSTUCTIONS
submit one fin rn. / //,'
9.Total well depth below land surface: `>K (ft.) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(l•200•and 2@100') construction to the following:
l2O Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: (ft•) 1617 Mail Service Center,Raleigh,NC 2 7699-1 6 1 7
If.tater lure/is above caving,use'.j" )
11.Borehole diameter: U /D (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: rU/v/y construction to the following:
(i.e.auger.rotdq',cable,direct push,etc.) Division of Water Quality,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
FOR WATER SUPPLY WELLS ONLY:
etc, 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gym) Method of test: the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form Gib'-1 NO1l11 Carolina Department of Environment and Natural Resoutces-Division of Water Quality Revised Jan.2013

VIA WNW Solf-erout Cortinestften
ate: (1 rRepa -- �.-
zol'� r - ; L I cyv�
r.
I that the above referenced well was grouted
appearance in acccadaace with
all County Well rules. I
wits - cl
CanstrUCtipte t lut:
Total tlx:Casing —
Depth:
Casing
r��
Dlt':_— -
Drive Shoe: